A mixed-methods study on speech and language disorders after the earthquake in Türkiye: awareness, service gaps, and lived experiences

Objective

This study examines societal awareness levels, service access barriers, and policy gaps regarding speech and language disorders (SLD) after the February 6, 2023 Kahramanmaraş earthquakes, utilizing a mixed-methods approach.

Methods

An explanatory sequential mixed-methods design was employed. A quantitative survey was conducted with 450 participants via stratified cluster sampling across four severely affected provinces. This was followed by qualitative in-depth interviews with 30 participants selected through purposive maximum variation sampling, using a semi-structured interview guide informed by the quantitative findings.

Results

59.3% of participants observed at least one SLD symptom in their families, yet only 19.5% received a formal diagnosis and 14.2% consulted a speech-language therapist. The mean awareness score was 41.2/75. Significant predictors of awareness included educational attainment (β = 0.312), presence of SLD symptoms (β = 0.241), and loss of a close relative (β = 0.211). Qualitative themes highlighted fear of stigmatization, lack of service awareness, prioritization issues, and weak system coordination.

Conclusion

A critical service gap exists in post-disaster SLD care in Türkiye. The findings suggest that the integration of SLD screening into disaster response systems, the strengthening of tele-therapy infrastructure, and the implementation of targeted community awareness initiatives may help improve access to speech–language services in post-disaster contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26833-3.

Highlights

Public health relevance—How does this work relate to a public health issue?

• This study addresses speech and language disorders as an underrecognized public health consequence of large-scale earthquakes.

• It situates post-disaster communication impairments within broader health system access and rehabilitation equity challenges.

Public health significance—Why is this work of significance to public health?

• The findings reveal a substantial gap between high symptom prevalence and extremely low utilization of speech-language therapy services after disaster exposure.

• Mixed-methods evidence identifies multi-layered barriers—individual, social, and systemic—that limit access to post-disaster rehabilitation care.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?

• Disaster health response frameworks should integrate routine screening and referral pathways for speech and language disorders.

• Public health policies must prioritize community awareness and tele-rehabilitation strategies to ensure equitable post-disaster recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26833-3.

Introduction

Earthquakes, beyond causing physical destruction, can trigger or exacerbate neurological and psychogenic speech and language disorders (SLDs) in survivors. Devastating disasters like the February 6, 2023 Kahramanmaraş earthquakes (7.7 and 7.6 Mw) have made post-traumatic communication disorders an urgent public health concern.

Post-disaster SLDs manifest in two main groups: (1) neurogenic disorders such as aphasia, dysarthria, and dysphagia due to traumatic brain injury, stroke, or hypoxia; and (2) psychogenic/functional disorders such as PTSD-related functional dysphonia, conversion symptoms, and increased stuttering [1]. The World Health Organization [9] emphasises that major earthquakes lead to increased traumatic brain injuries and functional impairments, and that communication and swallowing rehabilitation should be an integral part of the post-disaster health response.

However, in many countries, including Türkiye, the integration of speech-language pathology (SLP) services into disaster management is limited. ASHA [1] states that speech-language pathologists play a critical role in disaster response by identifying communication and swallowing disorders and providing psychosocial support and rehabilitation. In Türkiye, the limited number of SLPs and low awareness among primary care workers create a significant service gap in disaster zones.

This study aims to investigate the societal awareness level, service access barriers, and policy gaps regarding SLDs after an earthquake. It also seeks to provide recommendations for early screening, telepractice, and multidisciplinary team integration.

Research Questions:

1. What is the level of awareness about post-earthquake SLDs, and what factors influence it?

2. What are the barriers to accessing SLP services in disaster-affected regions?

3. How are the experiences of earthquake survivors with SLDs and their help-seeking processes shaped?

Method

Study design and setting

An explanatory sequential mixed-methods design was employed, comprising a quantitative cross-sectional survey followed by qualitative in-depth interviews. The study was conducted in the four provinces most severely affected by the February 2023 earthquakes: Hatay, Kahramanmaraş, Adıyaman, and Malatya.

Participants and sampling

• Quantitative Phase: A two-stage, stratified cluster sampling method was used. The primary stratum was Province. Clusters were defined as official temporary shelter sites (tent/container cities) and severely damaged urban neighborhoods. Ten clusters per province were randomly selected, proportionally representing shelter vs. neighborhood populations. Within clusters, a systematic sampling approach (e.g., every 5th unit in shelters, every 3rd household in neighborhoods) was applied, with the adult with the most recent birthday invited to participate. The final sample size was N = 450 (approx. 113 per province), calculated for a 95% CI with a 5% margin of error.

• Qualitative Phase: From the quantitative pool, 30 participants were selected via purposive maximum variation sampling to ensure diversity in awareness scores, symptom presence, service utilization, and trauma exposure. Recruitment continued until thematic saturation.

Inclusion/exclusion criteria & ethical approval

Participants were adults (≥ 18 years) present in the study regions during the earthquake and data collection, literate in Turkish, and provided written informed consent. Individuals with severe acute psychiatric/cognitive impairment or severe communication difficulties preventing independent participation were excluded. The study was approved by the İnönü University Non-Interventional Clinical Research Ethics Committee (Approval Code: 2025/9136; Date: 30 December 2025).

Data collection instruments and procedures

• Quantitative Instrument: The “Post-Earthquake Speech and Language Disorders Awareness and Access Questionnaire” (PE-SLD-AAQ) was developed for this study. Scale development involved expert review (CVI ≥ 0.80) and a pilot test with an independent sample (n = 50; data not included in the main analysis). Exploratory Factor Analysis (EFA) was conducted exclusively on an independent pilot sample (n = 50) for preliminary scale development and item refinement purposes. Pilot data were not included in the main study analyses. The finalized factor structure was subsequently applied to the full sample (N = 450), and internal consistency coefficients were recalculated in the main dataset, three-factor structure: General Awareness (10 items, α = 0.89), Symptom Recognition (8 items, α = 0.85), and Service Knowledge/Access (7 items, α = 0.82). The final questionnaire also included questions on symptom observation and service use.

• Qualitative Interviews: Semi-structured interviews (45–60 min) were conducted using a guide informed by quantitative findings. Interviews were audio-recorded and transcribed verbatim.

Data analysis

• Quantitative Analysis: Data were analyzed using IBM SPSS 25.0. Descriptive, bivariate (t-tests, ANOVA, chi-square), and multiple linear regression analyses were performed. Regression assumptions were checked, and VIF values confirmed no multicollinearity.

• Qualitative Analysis: Thematic analysis following Braun and Clarke’s framework was conducted. Two researchers independently coded the transcripts, and coding consistency was evaluated to enhance analytic rigor. Inter-coder agreement was high (Cohen’s κ = 0.81). Discrepancies were resolved through discussion, and final themes were refined collaboratively. Themes were refined through discussion and member checking.

• Integration: Quantitative results guided qualitative participant selection and interview questions. Qualitative findings were used to explain and contextualize the statistical patterns.

Findings

Descriptive statistics revealed a sample predominantly comprising women (61.8%) with low-to-medium education and high unemployment. Trauma exposure was severe: 41.6% had a family member trapped under rubble, 53.6% reported physical injuries, and 45.1% lost a close relative. Mental health diagnoses (PTSD/depression/anxiety) were reported by 64.2%, and 14.9% had neurogenic risks (TBI/stroke). Housing instability persisted, with 60.2% living in temporary shelters (Table 1).

Table 1.

Sociodemographic characteristics and earthquake-related trauma exposure of study participants (N = 450)

Variable	Category / Description	n	%	M ± SD
Gender	Female	278	61.8
	Male	172	38.2
Age (years)				41.2 ± 12.7
Education Level	Primary school or lower	147	32.7
	Middle school	98	21.8
	High school	126	28.0
	University or higher	79	17.6
Employment (Pre-earthquake)	Employed	201	44.7
	Unemployed / Homemaker / Retired / Student	249	55.3
Household Size				4.3 ± 1.8
Province Distribution	Hatay	112	24.9
	Kahramanmaraş	113	25.1
	Adıyaman	112	24.9
	Malatya	113	25.1
Trapped Under Rubble	Family member trapped	187	41.6
	None	263	58.4
Physical Injury	Injured family member(s)	241	53.6
	None	209	46.4
Loss of a Close Relative	First-degree relative lost	203	45.1
	None	247	54.9
Medical Diagnoses (Family Report)	Traumatic Brain Injury / Stroke	67	14.9
	Physical Disability	124	27.6
	PTSD / Depression / Anxiety	289	64.2
	Speech and Language Disorder	45	10.0
	None / Unknown	103	22.9
Housing Status	Tent / Container City	271	60.2
	Damaged House	134	29.8
	With Relatives / Another Province	45	10.0

M Mean, SD Standard Deviation, PTSD Post-Traumatic Stress Disorder

As shown in Table 2 SLD symptoms were widespread, with 59.3% of families reporting at least one symptom. The most common were voice disorders (39.6%) and word-finding difficulties (34.7%). Diagnosis and service access were strikingly low: only 19.5% of symptomatic families received a formal diagnosis, and merely 14.2% consulted a speech-language pathologist. Prominent reasons for not seeking care included lack of service awareness (64.2%), uncertainty about access (77.7%), and not viewing SLD as a priority (72.1%).

Table 2.

Prevalence and types of observed speech-language disorder (SLD) symptoms and associated service access barriers (N = 450)

Symptom Type (Multiple Response)	Families Reporting Symptom (n)	Families Reporting Symptom (%)
Hoarseness / deterioration in voice quality	178	39.6
Difficulty with word-finding / mental imagery	156	34.7
Difficulty expressing intended message	134	29.8
Difficulty understanding others	121	26.9
Swallowing difficulty / sensation of choking	112	24.9
Disrupted speech fluency (stuttering, blocking)	98	21.8
Total families observing AT LEAST ONE symptom	267	59.3
Service Access and Diagnosis Status (n = 267)	n	%
Received a Formal Diagnosis	52	19.5
Consulted a Speech-Language Pathologist (SLP)	38	14.2
Reasons for Not Consulting an SLP (n = 229)	n	%
Unaware of the existence of the SLP profession	147	64.2
Did not know how to access services	178	77.7
Financial constraints / transportation issues	92	40.2
Not perceived as a priority / believed to be temporary	165	72.1
Other	31	13.5

Descriptive statistics and multiple-response analysis were used. Service access data can be analyzed using the Chi-square test. Percentages for reasons for not consulting sum to more than 100% due to multiple responses

As shown in Table 3, the total awareness score was below the moderate level (M = 41.2 out of 75). Given that the theoretical midpoint of the scale is 45, scores below this value indicate insufficient overall awareness, particularly regarding service knowledge and access. The lowest score was in the “Service Knowledge and Access” sub-dimension (10.1/25). Reliability was high for all sub-dimensions and the total score (α > 0.80).

Table 3.

Descriptive statistics and reliability coefficients for the SLD awareness scale and its sub-dimensions

Sub-Dimension	Possible Score Range	Mean (M)	Std. Dev. (SD)	Cronbach’s α
General Knowledge and Awareness	5–25	16.8	4.2	0.89
Symptom Recognition	5–25	14.3	4.8	0.85
Service Knowledge and Access	5–25	10.1	5.1	0.82
TOTAL SCORE	15–75	41.2	10.7	0.91

Higher scores indicate higher awareness. Cronbach’s alpha coefficient was calculated for reliability (α > 0.80 indicates high reliability)

Table 4 presents group comparisons and regression analysis for awareness scores. Educational level was the strongest predictor (β = 0.312). Loss of a close relative (β = 0.211) and observation of SLD symptoms in the family (β = 0.241) were also significant predictors. Female gender and rubble experience were weaker but statistically significant predictors. The model explained approximately 36% of the variance in awareness scores (R² = 0.37).

Table 4.

Predictors of SLD awareness: group comparisons and multiple linear regression analysis results (N = 450)

Comparison Groups		n	Mean Score (M)	SD	Statistical Test (t/F, p)	β (Regression)
Gender	Female	278	42.5	10.1	t = 2.87, p=.004	0.117*
	Male	172	39.1	11.4
Education Level	University or higher	79	50.1	8.9	F = 21.34, p<.001	0.312***
	High school or lower	371	38.9	9.8
Trapped Under Rubble Experience	Yes	187	43.8	10.5	t = 3.45, p=.001	0.099*
	No	263	39.4	10.6
Loss of a Close Relative	Yes	203	44.6	10.9	t = 4.92, p<.001	0.211***
	No	247	38.4	9.8
Observed SLD Symptom in Family	Yes	267	44.9	10.3	t = 6.11, p<.001	0.241***
	No	183	35.8	9.1

Regression Model Summary: R = .61, R² = 0.37, Adjusted R² = 0.36, F(5, 444) = 52.18, p < .001 Note. *p < .05, ** p < .01, *** p < .001*

Qualitative findings: post-earthquake sld experiences and service access processes

The interrelationship between the core experience of SLD symptoms and the subsequent multi-layered barriers to care is visualized in the thematic map (Fig. 1). Thematic analysis of in-depth interviews with 30 participants revealed four main themes: (1) Fear of Stigmatization and Social Isolation, (2) Lack of Service Awareness and Information Inconsistency, (3) Prioritization Issue: “Survival Comes First”, and (4) Weak Intra-System Coordination. Each theme is presented below and linked to the quantitative findings.

Fig. 1.

Thematic map of barriers to post-earthquake speech and language disorder (SLD) Service Access

Theme 1: fear of stigmatisation and social isolation

A significant proportion of participants stated that they were reluctant to disclose the speech and language problems they observed in their families to those around them. Concerns that symptoms such as stuttering and psychogenic voice loss, particularly in children, would be perceived as a ‘weakness’ or ‘deficiency’ negatively affected families’ behaviour in seeking help.

‘My son started stuttering after the earthquake. But I don’t want the neighbours to hear, I don’t want them to think he’s “traumatised”. Everyone has their own problems already, we don’t want to add to them.’ (K12).

Theme 2: lack of awareness of services and information mismatch

The vast majority of participants (27/30) stated that they were unaware of the profession of speech and language therapist or did not know what this service was for. The lack of information about access routes to the service parallels the 77.7% rate in our quantitative findings.

‘My daughter has difficulty swallowing food and gags. We took her to the doctor, who said there was nothing physically wrong. So what should we do? Who should we go to? I don’t know. A speech therapist? What’s that? I’ve never heard of it before.’ (K7, female, 38 years old, daughter has dysphagia).

Some participants (8/30) stated that when they tried to access the service, they received conflicting information (‘it’s available at a private centre’, ‘make an appointment at a state hospital’, ‘go to a psychiatrist’) and that this discouraged them.

Theme 3: the problem of prioritisation - ‘Survival First’

Almost all participants (28/30) emphasised that their lives after the earthquake revolved around basic needs such as ‘survival’, “shelter” and ‘safety’, and that language and speech problems took a back seat to these urgent needs. This finding provides an in-depth explanation for the ‘not a priority’ response (72.1%) in the quantitative data.

‘Yes, my speech is impaired, but our biggest concern right now is shelter. There are seven of us in a container. If we could find a job and get ourselves back on our feet, then maybe we could look into the speech issue. It’s not the right time now.’ (K19, female, 35 years old, husband has psychogenic dysphonia).

Theme 4: weakness in internal system coordination

The few participants who managed to access the service (4/30) complained about the inadequacy of referral mechanisms within the healthcare system. It was reported that speech and language assessment is not automatically performed for individuals who have suffered traumatic brain injury or stroke, and that this service is not provided unless requested by families.

‘My mother was trapped under the rubble and suffered a head injury. Her speech was impaired. We told the neurology professor, and he said, “She will recover”. But how will she recover? No one taught us anything; they didn’t even give her physical therapy. We were on our own.’ (K24, female, 51 years old, mother with traumatic aphasia).

These four themes reveal that the barriers to accessing SLD services after the earthquake are multi-layered. Individual (fear of stigmatisation), cognitive (lack of awareness), situational (life priorities), and systemic (weak coordination) factors provide an in-depth explanation for the low service utilisation rate (14.2%) observed in the quantitative findings.

Discussion

This study is one of the first comprehensive field studies to reveal the awareness level, symptom observations, and service access barriers regarding SLDs following a mass trauma like the 2023 Kahramanmaraş earthquakes. Our findings both confirm expected outcomes in light of the literature and expose serious, urgently addressable gaps specific to Türkiye.

Evaluation of key findings in the context of the literature

High prevalence of symptoms and low diagnosis rate

The prevalence of SLD symptoms (59.3%) aligns with global reports linking post-disaster communication disorders to traumatic brain injury (TBI) and psychological stress (WHO, 2023). For instance, severe earthquakes may result in TBI rates of 15–20%, often leading to aphasia or dysarthria [6]. However, the low diagnosis rate (19.5%) highlights inadequate neurological screening in disaster zones, reinforcing SLDs as an “invisible disability.” [The near-total absence of SLD screening in Türkiye’s post-disaster health response stands in contrast to the integration of early mental health interventions seen in other major disaster settings, such as post-tsunami Japan [7], highlighting a critical divergence from comprehensive psychosocial care models.] Consistent with Battle’s (2015) foundational work, communication disabilities often remain “invisible” during disasters, despite their profound implications for autonomy, dignity, and equitable access to care. Our findings reinforce this perspective by demonstrating that speech and language disorders were widely observed yet rarely recognized as a legitimate rehabilitation priority in the post-earthquake context.

Critical service access gap: a multi-layered barrier system

Only 14.2% of symptomatic families consulted a speech-language pathologist (SLP). Our mixed-methods design reveals that the primary quantitative barriers—lack of information (64–78%) and low prioritization (72%)—are not isolated issues but are deeply interconnected and reinforced by qualitative experiences. The qualitative data provide a crucial explanatory layer: the fear of stigmatization (Theme 1) fundamentally shapes the perception of SLDs as a non-priority. When communication difficulties are internalized as a personal weakness or a shameful mark of trauma, families are less likely to categorize them as a legitimate health concern demanding immediate action. This stigma-driven silence directly feeds the quantitative finding that problems are “not perceived as a priority” (72.1%). Concurrently, the absolute lack of service awareness (Theme 2) and the contextual imperative of “survival first” (Theme 3) create a perfect storm where the motivation to seek help is extinguished by not knowing where to turn, all while basic needs dominate daily life. This multi-layered barrier system, culminating in weak intra-system coordination (Theme 4), explains the severe service gap more comprehensively than quantitative data alone. These coordination challenges are consistent with disaster management lessons reported for people with communication disorders in Türkiye, which emphasize the need for multidisciplinary planning and clearer role definitions within emergency health systems (Birol & Yaşar Gündüz, 2024). Our findings extend this work by illustrating how such coordination gaps are directly experienced by affected families in the post-earthquake context. These findings closely align with the experiences reported by speech–language pathologists working in post-earthquake Türkiye, who described disrupted service delivery, workforce strain, and the absence of coordinated referral mechanisms (Birol, Gündüz, & Tutuş, 2026). The convergence between survivor perspectives and professional accounts strengthens the credibility of the identified system-level barriers. Recent disaster-preparedness research emphasizes the importance of structured planning tools for individuals with communication needs. For example, Barton-Hulsey et al. (2023) demonstrated that toolkit-based preparedness approaches can significantly enhance emergency readiness for individuals who use augmentative and alternative communication, supporting the need for anticipatory, rather than reactive, service models.

Awareness level and determinants

Overall awareness was below moderate (41.2/75), with particularly low scores in service knowledge (10.1/25)—[a level strikingly lower than general health literacy rates reported in other post-disaster studies in low- and middle-income countries (e.g.,[8]), suggesting a profession-specific visibility crisis for SLPs in Türkiye.] Regression confirmed education as the strongest predictor, consistent with health literacy models [3]. Greater trauma exposure (loss of relative, entrapment) correlated with higher awareness, possibly due to increased health-seeking motivation. Women’s higher awareness aligns with documented gender roles in caregiving and health behavior [5]. This finding suggests that awareness in the study population does not reach a functional level sufficient to support timely help-seeking behaviors in post-disaster contexts.

Policy and practice implications

Our findings highlight the need for carefully considered reforms in disaster management and rehabilitation services, informed by the observed gaps in awareness and service access that move beyond general recommendations to actionable steps:

1. Integrate SLPs into Disaster Response Protocols with Concrete Tools: Frontline teams should receive basic training to recognize early signs of speech and language disorders (SLDs). This may be operationalized by embedding standardized SLD screening items (e.g., “Does the person have difficulty speaking or swallowing?”) into national post-disaster health assessment forms, such as the AFAD Emergency Health Assessment Form. In addition, SLP referral pathways for individuals with suspected traumatic brain injury or stroke should be clearly defined and incorporated into the Turkish Disaster Response Plan (TAMP), where feasible. These recommendations should be interpreted as context-specific and exploratory, given the cross-sectional design and reliance on self-reported data.

2. Enhance SLP Capacity and Telepractice with Context-Sensitive Targets: Increasing the number of speech–language pathologists (SLPs) in state hospitals and community health centers in earthquake-prone regions may help address post-disaster service gaps. Rather than fixed mandates, context-sensitive workforce planning targets (e.g., approximately one SLP per 50,000 people in high-risk provinces) may serve as a reference point for policy development. In addition, tele-rehabilitation may represent a feasible and scalable strategy to improve access to speech–language services in post-disaster contexts, particularly where in-person care is limited. Consideration may also be given to the inclusion of tele-SLP services within national health insurance reimbursement frameworks (SGK), including the development of post-disaster–specific reimbursement mechanisms.

   Given the cross-sectional design and reliance on self-reported data, these implications should be interpreted as context-specific and exploratory, rather than prescriptive or universally generalizable.

3. Launch Targeted Awareness Campaigns with Specific Messaging: Develop clear, accessible public information. Campaigns should be co-designed with community leaders and use simple, destigmatizing messaging (e.g., "After the earthquake, difficulty speaking is common and treatable. Help is available."). Training modules on SLD recognition should be integrated into the continuing education programs for Family Physicians working in affected regions.n the cross-sectional design and reliance on self-reported.

4. Develop and Disseminate Practical Access Tools: Create and distribute "SLD Access Roadmaps" in disaster zones—visual guides available in community centers and via SMS—that clearly outline the steps from symptom recognition to accessing a free SLP consultation.

International context and Türkiye’s position

International evidence confirms that psychosocial and mental health impacts of major earthquakes persist for years [2, 7]. While Türkiye’s response remains focused on acute physical interventions, communication-based rehabilitation is largely absent from systematic planning. This gap mirrors challenges seen in other resource-constrained, disaster-prone settings where rehabilitation services are chronically under-prioritized, but it is exacerbated in the Turkish context by the exceptionally low baseline awareness of SLP services. This underscores the need for multidisciplinary, psychosocially-informed rehabilitation policies that specifically address invisible disabilities like SLDs [4].

Study strengths and limitations

This study has several notable strengths that bolster the credibility and applicability of its findings. First, the use of an explanatory sequential mixed-methods design allowed for a comprehensive exploration of the issue, with qualitative data providing rich, contextual explanations for the quantitative patterns. Second, data collection was conducted in the field under challenging post-disaster conditions, enhancing the ecological validity of the findings. Third, the sampling strategy employed maximum variation sampling for the qualitative phase, ensuring that a wide spectrum of experiences from severely affected individuals was captured, leading to more robust and transferable themes.

Limitations

• Self-reported data without clinical verification.

• Limited sample representativeness: excluded migrants and institutionalized individuals.

• Cross-sectional design prevents causal inference.

Future research recommendations.

• Longitudinal studies to track SLD progression and long-term needs.

• Mixed-methods designs to deepen understanding of stigma, hope, and resilience.

• Intervention studies evaluating brief SLP protocols in disaster settings.

Conclusion

The 2023 earthquakes have exposed a critical gap in Türkiye’s post-disaster rehabilitation system: severely inadequate awareness and service access for neurogenic and psychogenic speech-language disorders. The findings demonstrate that a traditional disaster response, focused predominantly on physical injuries, overlooks communication functions essential for recovery and community participation. For inclusive and dignified rehabilitation, speech-language pathology services must be integrated into the core of the disaster cycle and prioritized urgently by policymakers, health planners, and practitioners.

Abbreviations

SLD

Speech and language disorders

SLP

Speech-language pathologist/therapist

TBI

Traumatic Brain Injury

PTSD

Post-Traumatic Stress Disorder

ASHA

American Speech-Language-Hearing Association

WHO

World Health Organization

Authors’ contributions

**A.Ş.** : Conceptualization, methodology, investigation, formal analysis, writing – original draft, writing – review & editing, supervision, project administration. **T.K.** : Methodology, investigation, data curation, formal analysis, writing – original draft, writing – review & editing.All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

Due to ethical and privacy constraints, the datasets generated and analyzed during the current study are not publicly available. However, they are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the İnönü University Non-Interventional Clinical Research Ethics Committee (Approval Code: 2025/9136; Date: 30 December 2025). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their involvement in the study.

Consent for publication

Not applicable. This manuscript does not contain data from any individual person in a form that requires specific consent for publication.

Competing interests

The authors declare no competing interests.